JOINT SERVICE SUB AQUA DIVING DIVING ILLNESS’ & TREATMENT REVIEWDIVING REVIEW

Diving Illness’ & Treatment Review Diving Illness’ & Treatment Review 2 06/2011 Objectives Revise Basic Life Support (BLS) skills For diving incidents: understand the conditions recognise signs and symptoms understand how oxygen administration benefits these conditions Understand appropriate equipment and the practicalities of its use Revise oxygen administration skills breathing casualties non-breathing casualties

Diving Illness’ & Treatment Review Diving Illness’ & Treatment Review 3 06/2011 Outline BLS In-Water Rescue Medical conditions Casualty Assessment Oxygen administration equipment Oxygen administration in practice

Diving Illness’ & Treatment Review Diving Illness’ & Treatment Review 4 06/2011

BASIC LIFE SUPPORT (BLS)

Diving Illness’ & Treatment Review Diving Illness’ & Treatment Review DT2.6 08/02 Lesson Outline BLS skills: Essential rescue skills Deteriorate quickly if not frequently exercised Advice/techniques evolve Basis on which to build oxygen-enriched RB: Will inevitably be needed while equipment is readied Will form basis of oxygen- enriched basic life support

Diving Illness’ & Treatment Review Diving Illness’ & Treatment Review 7 06/2011 Assessing the Need Indicators of the need for BLS: no response no chest movement no feel of air movement

Diving Illness’ & Treatment Review Diving Illness’ & Treatment Review DT2.8 08/02 Assessing the Need Indicators of the need for BLS: !No response !No chest movement !No feel of air movement

Diving Illness’ & Treatment Review Diving Illness’ & Treatment Review 9 06/2011 Priorities D r A B C Danger – to casualty and rescuer Response (AVPU) Airway Breathing Compressions

Diving Illness’ & Treatment Review Diving Illness’ & Treatment Review 10 06/2011 Clear Airway Foreign objects Tongue Airway blocked by tongue Head tilt/chin lift clears airway

Diving Illness’ & Treatment Review Diving Illness’ & Treatment Review 11 06/2011 Priorities Danger – to casualty and rescuer Response A – Alert V – Responds to Voice P – Responds to Pain U – Unresponsive Airway – clear of obstructions Breathing – check for normal breathing (10 secs.) Compressions – Cardiac Compressions

Diving Illness’ & Treatment Review Diving Illness’ & Treatment Review 12 06/2011 BLS: Decision Process Unresponsive Recovery position Leave casualty and get help Shout for help, open up airway Breathing normally?Leave casualty and get help, return & give 30CCs No Yes Stop to recheck only if breathing resumes, else continue until: Qualified help arrives Normal breathing You are exhausted

Diving Illness’ & Treatment Review Diving Illness’ & Treatment Review 13 06/2011 Basic Life Support Sequence of 30 compressions: 2 breaths by one rescuer Two rescuers: change role every 1-2 minutes Monitor effectiveness Stop if normal breathing resumes/medical assistance arrives

Diving Illness’ & Treatment Review Diving Illness’ & Treatment Review 14 06/2011 Basic Life Support - CC Place heel of hand in centre of chest Place heel of other hand on top of first hand Straight arms – press down on sternum 5-6 cm Repeat at times/min

Diving Illness’ & Treatment Review Diving Illness’ & Treatment Review 15 06/2011 Basic Life Support - RB Expired air can sustain life Monitor effectiveness Continue until qualified help comes, the casualty is breathing normally or you are exhausted Sight Feel Sound Appearance Don’t over ventilate Don’t over ventilate

Diving Illness’ & Treatment Review Diving Illness’ & Treatment Review 16 06/2011 Don’t over ventilate Don’t over ventilate Breaths are to be No more than 1 second each 2 breaths to take no more than 5 seconds Don’t attempt more than 2 breaths each cycle Regurgitation Not always normal vomiting Monitor exhalation sounds Basic Life Support - RB

Diving Illness’ & Treatment Review Diving Illness’ & Treatment Review 17 06/2011 Recovery Position If casualty breathing place in recovery position The ‘how’ position More stable position

Diving Illness’ & Treatment Review Diving Illness’ & Treatment Review 18 06/2011

IN-WATER RESCUE

Diving Illness’ & Treatment Review Diving Illness’ & Treatment Review 20 06/2011 In Water Life Support Sequence Make Buoyant Extend Airway RB for 1 minute Standing depth/Boat 1 min. RB De-Kit & Land Tow, RB - 2 every 15 secs.

Diving Illness’ & Treatment Review Diving Illness’ & Treatment Review 21 06/2011 Rescue - to the surface Diver out of gas AS Ascent Incapable/unconscious diver CBL Rescue ascents - Urgent Ascend directly to surface May mean ignoring decompression stops Divers safer at surface DCI can be treated Actions to take in case of oxygen convulsions Controlled Buoyant Lift AS ascent

Diving Illness’ & Treatment Review Diving Illness’ & Treatment Review 22 06/2011 Surface Tows to Shore Summon help Ensure casualty buoyant at surface Fully inflate BC - face clear of water Consider removing weights Summon assistance Conscious casualty Reassure Unconscious casualty Remove mask, mouthpiece and extend airway Non Breathing casualty Remove mask, mouthpiece and give RB for 1 minute i.e. 10RBs

Diving Illness’ & Treatment Review Diving Illness’ & Treatment Review 23 06/2011 Landing Casualty - Shore Standing depth Continue RB for a further 1 minute De-kit and land as quickly as possible WITHOUT further rescue breathing Lift from water Contact emergency services Continue BLS

Diving Illness’ & Treatment Review Diving Illness’ & Treatment Review 24 06/2011 Landing Casualty - Boat Assistance available At boat prior to landing Continue RB for a further 1 minute De-Kit and remove from water as quickly as possible WITHOUT further RB Contact emergency services Continue BLS

Diving Illness’ & Treatment Review Diving Illness’ & Treatment Review 25 06/2011 Effective Rescues Typical indications Nervous or reluctant Excuses or repeated questions Stress indicators Slow kit up or constant fiddling Concerns need to be resolved Adapt the dive plan More suitable dive site Peer pressure

Diving Illness’ & Treatment Review Diving Illness’ & Treatment Review 26 06/2011 Pre-Dive Buddy Awareness Buddy reactions Stopping for no reason Preoccupation with kit Slow response to signals Rapid breathing Wide staring eyes Resolve quickly Stop or move to buddy OK? Problem? Not OK, gentle but firm contact Abort dive

Diving Illness’ & Treatment Review Diving Illness’ & Treatment Review 27 06/2011

MEDICAL CONDITIONS

Diving Illness’ & Treatment Review Diving Illness’ & Treatment Review 29 06/2011 Oxygen Exposure At high concentrations oxygen is toxic PO 2 <0.16 bar does not support life Need to remain within accepted oxygen exposure limits Hyperoxic Oxygen Partial Pressure Scale (bar) Short term toxicity risk Long term toxicity risk Hypoxic Unconsciousness Abilities impaired AIR

Diving Illness’ & Treatment Review Diving Illness’ & Treatment Review 30 06/2011 Hypoxia What is it: Lack of oxygen PO2< 0.16 bar Hypoxic Unconsciousness Abilities impaired AIR

Diving Illness’ & Treatment Review Diving Illness’ & Treatment Review 31 06/2011 Hypoxia Symptoms: Inability to think clearly, confusion, sense of losing it Loss of co-ordination Unconsciousness, death Primary danger is symptoms may be vague or absent It can occur suddenly and without warning! Hypoxic Unconsciousness Abilities impaired AIR

Diving Illness’ & Treatment Review Diving Illness’ & Treatment Review 32 06/2011 Hyperoxic What is it: Too much oxygen Oxygen becomes toxic at elevated partial pressures There are two different effects of Hyperoxia: Whole Body Oxygen Toxicity when PO 2 >0.5 bar for long periods Central Nervous System (CNS) toxicity when PO 2 >1.4 bar for even short periods Hyperoxic Short term toxicity risk Long term toxicity risk AIR

Diving Illness’ & Treatment Review Diving Illness’ & Treatment Review 33 06/2011 Whole Body Toxicity Cause: long exposures to PO 2 >0.5 bar Monitored to allow for recompression treatment Physiological reactions including: Inflammation in the lungs Reduction in vital capacity Congestion, oedema, bronchitis, swelling of alveolar walls, thickening of pulmonary arteries Visual impairment Symptoms: Dry cough, discomfort in breathing cycle, increased breathing resistance, shortness of breath, Severe pain, sub-sternal pain or burning Temporary short sightedness (Hyperoxic Myopia)

Diving Illness’ & Treatment Review Diving Illness’ & Treatment Review 34 06/2011 CNS Toxicity Also known as Acute Oxygen Toxicity Reaction to PO 2 generally > 1.4 bar Symptoms: CON- Convulsions V- Vision E- Ears, hearing disturbances N- Nausea T- Twitching I- Irritability D- Dizziness Until convulsions begin, minor symptoms: Can occur in ANY order or combination Increase in severity

Diving Illness’ & Treatment Review Diving Illness’ & Treatment Review 35 06/2011 CNS Toxicity Convulsions Tonic phase – do not assist Muscles become tense Casualty becomes rigid and holds breath Clonic phase – do not assist May occur seconds or minutes after the tonic phase Casualty jerks violently (convulsion) Depressive phase - assist Casualty relaxes and is unconscious Potential loss of mouthpiece Loop flood – loss of buoyancy Need for Basic Life Support?

Diving Illness’ & Treatment Review Diving Illness’ & Treatment Review 36 06/2011 CNS Toxicity Convulsions Phases can occur on surface or after PO 2 is reduced (‘Off effect’) Progressive damage to nervous system with each successive convulsion

Diving Illness’ & Treatment Review Diving Illness’ & Treatment Review 37 06/2011 Hyperoxia Causes: Inaccurate dive planning Failure to analyse gas Incorrect marking or fitting of cylinders Hyperoxic Short term toxicity risk Long term toxicity risk AIR

Diving Illness’ & Treatment Review Diving Illness’ & Treatment Review 38 06/2011 Hyperoxia Aggravating factors: Actual PO 2 Duration of exposure Level of exertion Cumulative O 2 exposure Hyperoxic Short term toxicity risk Long term toxicity risk AIR

Diving Illness’ & Treatment Review Diving Illness’ & Treatment Review 39 06/2011 Hyperoxia Avoidance: High PCO 2 predisposes to oxygen toxicity Accurately track your oxygen exposure Hyperoxic Short term toxicity risk Long term toxicity risk AIR

Diving Illness’ & Treatment Review Diving Illness’ & Treatment Review 40 06/2011 Monitoring Oxygen Exposure CNS and Whole Body Toxicity need to be monitored separately Data for both provided in BSAC Oxygen Toxicity Table Dive planning software Nitrox & mixed gas decompression computers

Diving Illness’ & Treatment Review Diving Illness’ & Treatment Review 41 06/2011 Hypercapnia What is it: Excess CO 2 in the blood Cause: High inspired PCO 2 Poor ventilation of diver’s lungs at depth due to increased gas density Absorbent material exhausted in rebreathers Channelling in absorbent material rebreathers CO 2

Diving Illness’ & Treatment Review Diving Illness’ & Treatment Review 42 06/2011 Hypercapnia Symptoms 0.03 bar PCO 2 doubles breathing rate (dyspnea) 0.06 bar PCO 2 distress, confusion, lack of coordination 0.10 bar PCO 2 severe mental impairment 0.12 bar PCO 2 loss of consciousness, death CO 2

Diving Illness’ & Treatment Review Diving Illness’ & Treatment Review 43 06/2011 Hypercapnia Further impact Increases oxygen toxicity potential Increases potential for DCI and narcosis Avoidance Meticulous preparation & monitoring of absorbent life - rebreathers Avoiding over exertion Resolution Stop, slow down breathing rate, relax Bail out to open circuit - rebreathers CO 2

Diving Illness’ & Treatment Review Diving Illness’ & Treatment Review 44 06/2011 Decompression illness Causes inadequate elimination of nitrogen from the body during ascent Physical damage to the alveoli due to overpressure introduces bubbles of air (emboli) into the blood Patent foramen ovale (PFO) allows bubbles to pass from venous to arterial circulation Bubbles blocking blood flow Bubbles in tissues compress blood vessels

Diving Illness’ & Treatment Review Diving Illness’ & Treatment Review 45 06/2011 Decompression illness Signs and symptoms Denial! Itches, rashes Numbness, tingling, joint pains Vision disturbances Dizziness, nausea, headaches, confusion Weakness, paralysis, loss of bladder/bowel control Shortness of breath Shock, unconsciousness Any abnormality after a dive Signs and symptoms appear from seconds to many hours after surfacing

Diving Illness’ & Treatment Review Diving Illness’ & Treatment Review 46 06/2011 Decompression illness On-site first aid Lie casualty down flat Keep casualty quiet Administer 100% oxygen Increased nitrogen pressure gradient assists in nitrogen elimination from bubbles in blood and tissue The higher the percentage of oxygen the more effective – whenever possible administer 100% Improved oxygen supply to tissues where blood flow is reduced due to bubble blockage Treat for shock Evacuate to a recompression facility as soon as possible

Diving Illness’ & Treatment Review Diving Illness’ & Treatment Review 47 06/2011 Burst Lung Cause Physical damage to lung tissue from over-extension due to over-pressurisation Types Both types can occur in isolation but are usually accompanied by air embolism Collapsed lung (pneumothorax) Bubbles between organs and tissues (emphysema)

Diving Illness’ & Treatment Review Diving Illness’ & Treatment Review 48 06/2011 Burst Lung Signs and symptoms chest discomfort/pain, bloody froth shortness of breath changes to vocal tone, crepitation shock unconsciousness, death Signs and symptoms of burst lung are frequently accompanied by those for decompression illness

Diving Illness’ & Treatment Review Diving Illness’ & Treatment Review 49 06/2011 Burst Lung On-site first aid Lie casualty down Keep casualty quiet Administer 100% oxygen Assists in re-absorption of the nitrogen content of air in pneumothorax or emphysema Offsets reduced effective lung surface area for gas transfer due to collapsed lung Treat for shock Evacuate to a recompression facility as soon as possible

Diving Illness’ & Treatment Review Diving Illness’ & Treatment Review 50 06/2011 Near Drowning Cause Respiratory interruption due to fluid inhalation Signs and symptoms Circumstances No breathing Cyanosis – ashen grey / blue appearance Weak or absent pulse

Diving Illness’ & Treatment Review Diving Illness’ & Treatment Review 51 06/2011 Near Drowning On-site first aid Rescue Breathing Oxygen-enriched if possible Concentration of oxygen reaching the casualty’s lungs during RBs is increased Chest compressions if required Recovery position Evacuate to medical attention Even if apparently fully recovered Complications of secondary drowning

Diving Illness’ & Treatment Review Diving Illness’ & Treatment Review 52 06/2011 Shock Definition inadequate circulation leading to tissue damage due to inadequate oxygenation and waste removal Present to a greater or lesser degree in all injuries Mechanisms reduced blood volume (bleeding, burns, oedema) massive dilation of blood vessels (e.g. fainting) inadequate cardiac output (e.g. heart attack) allergic reaction to drugs, food or stings removal from the water after prolonged immersion

Diving Illness’ & Treatment Review Diving Illness’ & Treatment Review 53 06/2011 Shock Signs and symptoms weakness, dizziness pallor, sweating rapid pulse rate rapid breathing, feeling breathless unconsciousness

Diving Illness’ & Treatment Review Diving Illness’ & Treatment Review 54 06/2011 Shock On-site first aid Treat prime cause Reassure casualty (TLC) Keep casualty quiet Lay casualty down with legs raised (not in the case of DCI or burst lung) Keep warm and comfortable Administer oxygen Increased oxygen dissolved in the blood offsets effects of inadequate circulation Monitor condition Nothing by mouth (except for DCI) Evacuate to medical attention

Diving Illness’ & Treatment Review Diving Illness’ & Treatment Review 55 06/2011 Shock Immersion shock Extreme form of blood vessel dilation due to prolonged immersion Muscles relax due to water supporting body weight If removed from water upright, blood can pool in lower limbs – potentially fatal Keep casualty horizontal at all times Discourage any movement or activity by the casualty

Diving Illness’ & Treatment Review Diving Illness’ & Treatment Review 56 06/2011 Carbon Monoxide Poisoning Cause breathing gas contaminated with carbon monoxide Effect carbon monoxide combines about 200 times more readily with haemoglobin than does oxygen interferes with the blood's ability to transport oxygen may act as a cellular poison

Diving Illness’ & Treatment Review Diving Illness’ & Treatment Review 57 06/2011 Carbon Monoxide Poisoning Signs and symptoms headache pale or greyish appearance weakness dizziness, nausea tunnel vision vomiting rapid pulse rapid breathing coma convulsions

Diving Illness’ & Treatment Review Diving Illness’ & Treatment Review 58 06/2011

CASUALTY ASSESSMENT

Diving Illness’ & Treatment Review Diving Illness’ & Treatment Review 60 06/2011 Incident Procedure - Front

Diving Illness’ & Treatment Review Diving Illness’ & Treatment Review 61 06/2011 Incident Procedure - Back

Diving Illness’ & Treatment Review Diving Illness’ & Treatment Review 62 06/2011

DT /02 Oxygen Administration Equipment

Diving Illness’ & Treatment Review Diving Illness’ & Treatment Review DT /2008 Gas Cylinders ‘D’ size most convenient 370 to 540 litres (136 to 210 bar) Larger cylinders available but often more convenient to carry more smaller ones Colour coding – (BS EN ) White shoulder Body any non-allocated colour but usually black Pillar valve connections (BS EN 850) Two pin index holes Female outlet, no ‘O’ ring

Diving Illness’ & Treatment Review Diving Illness’ & Treatment Review DT /2008 Regulators Outlet pressure Approximately 4 bar (some higher) Constant outlet pressure Inlet Two index pins Male inlet with sealing washer Simple pressure gauge Outlets capable of supporting: At least one demand valve (100 to 160 litres / min. flow rate) 10 litres/min. (minimum) constant flow

Diving Illness’ & Treatment Review Diving Illness’ & Treatment Review DT /2008 Demand Valves Provide oxygen on demand Can be capable of flow rates of up to 160 litres / min. Fitted with oro-nasal mask Transparent material Inflated or double face seal Large/adult and small/child sizes

Diving Illness’ & Treatment Review Diving Illness’ & Treatment Review DT /2008 Demand / Resuscitation Valves Available types Automatic Manually controlled Configuration suitable for sport diver use: Manually controlled 100 – 160 litres min. flowrate on demand Resuscitation control limited to a maximum flow rate of 40 litres /min Over pressure relief valves (set to a pressure of approx 45cm of water)

Diving Illness’ & Treatment Review Diving Illness’ & Treatment Review DT /2008 ‘Pocket’ Masks Central ventilation orifice !May be fitted with a porous splash guard !May be supplied with an optional non- return / exhalation valve Transparent material Generally have inflated face seal Connection (with non-return valve) for constant flow oxygen tubing

Diving Illness’ & Treatment Review Diving Illness’ & Treatment Review DT /2008 Reservoir mask aka Hudson/non-rebreathing For second DCI casualty Gives oxygen concentration Higher than pocket mask Not as high as demand mask Parts Oxygen tubing Reservoir Mask Exhaust valves Flow l/min Fill bag before use

Diving Illness’ & Treatment Review Diving Illness’ & Treatment Review DT /2008 Storage Cases Storage cases should be: Robust Waterproof Ideally store equipment in fully assembled state Case must have a pressure release valve if used to store cylinder

Diving Illness’ & Treatment Review Diving Illness’ & Treatment Review DT /2008 Precautions in Use Fire risk - absolute cleanliness a necessity Keep equipment regularly maintained Do-it-yourself equipment or modifications are dangerous Do not use non-standard equipment – risk of confusion

Diving Illness’ & Treatment Review Diving Illness’ & Treatment Review DT /2008

OXYGEN ADMINISTRATION IN PRACTICE

Diving Illness’ & Treatment Review Diving Illness’ & Treatment Review 74 06/2011 Casualties Incident statistics show that the majority of casualties will be Breathing Conscious Suffering from decompression illness Will need the use of a demand valve and oro-nasal mask for maximum oxygen concentration Incidence of casualties requiring Rescue Breaths is much lower

Diving Illness’ & Treatment Review Diving Illness’ & Treatment Review DT /02 Posture For decompression illness or burst lung, lay casualty flat on back If decompression illness or burst lung is not involved Legs may be raised to counter shock Monitor for signs of adverse impact on casualty’s breathing

Diving Illness’ & Treatment Review Diving Illness’ & Treatment Review 76 06/2011 Administering Oxygen Start at the earliest opportunity Greater nitrogen pressure gradient Earliest reduction in tissue hypoxia Don’t ration oxygen Tender loving care (TLC) For a second casualty Use second demand valve and oro-nasal mask, if available Otherwise use a pocket mask Accept faster consumption of oxygen

Diving Illness’ & Treatment Review Diving Illness’ & Treatment Review 77 06/2011 Administering Oxygen Be prepared for a possible transient worsening of casualty’s condition Initial reaction of brain to increased oxygen Oxygen diffusing into bubbles Oxygen toxicity Not a problem at surface pressure / durations involved Casualties of underwater O 2 toxicity? – administer O 2 on surface once any signs or symptoms have disappeared No pain killers

Diving Illness’ & Treatment Review Diving Illness’ & Treatment Review 78 06/2011 Administering Fluids Counter dehydration with fluids Still isotonic drinks best, or water/squash Do not administer caffeinated or fizzy drinks Small amounts, at a rate of approx 1 litre/hour Do not allow to interfere with or delay Administration of oxygen Evacuation to a recompression facility Do not administer fluids if Casualty is likely to vomit Casualty is likely to inhale fluid A general anaesthetic may be required If no oxygen, fluids alone are beneficial

Diving Illness’ & Treatment Review Diving Illness’ & Treatment Review 79 06/2011 Evacuation Don’t delay call to emergency services Coastguard: VHF Channel 16 DDMO / BHA DCI Helplines: England, Wales & N. Ireland: Scotland: On Land (other) Ambulance/Police/Coastguard Telephone: 999 or 112 DCI Irrespective of any apparent improvement, casualty must get medical attention Casualty’s buddy? All relevant information must accompany any casualty

Diving Illness’ & Treatment Review Diving Illness’ & Treatment Review 80 06/2011 Oxygen Supply Exhausted? Closed Circuit Rebreather Can be set to deliver 100% oxygen Nitrox Open Circuit or Semi Closed Circuit Rebreather Reduces the amount of inspired nitrogen Not as effective as 100% oxygen but better than breathing air Common Considerations Mouthpiece may not be tolerated Oxygen % reduced by air inspired via nose

Diving Illness’ & Treatment Review Diving Illness’ & Treatment Review 81 06/2011 Missed Decompression If a diver misses decompression stops for any reason, or is subject to a rapid ascent such that it is considered that they may suffer decompression illness as a result… Do not wait for signs/symptoms to appear Lay casualty down and keep quiet Administer oxygen/fluids Seek specialist medical advice on further action from the DDMO/ BHA Help lines

Diving Illness’ & Treatment Review Diving Illness’ & Treatment Review 82 06/2011 Entonox Mixture of oxygen and nitrous oxide Nitrous oxide is very soluble in blood Large quantity of nitrous oxide passes into nitrogen bubbles to re-establish equilibrium Causes size of bubbles to increase Never administer to a casualty suffering from a diving accident Do not administer to a casualty of a non-diving accident if this follows diving Ensure emergency personnel fully understand - Do this tactfully!

Diving Illness’ & Treatment Review Diving Illness’ & Treatment Review DT /02 Summary Administration of oxygen is beneficial to the major diving disorders 100% oxygen will provide the maximum benefit Administer oxygen as early as possible Oxygen is a supplement to other first aid procedures to increase their effectiveness Casualty must always be evacuated to appropriate medical aid : As soon as possible Irrespective of any apparent resolution of their condition

Diving Illness’ & Treatment Review Diving Illness’ & Treatment Review 84 06/2011 Final Summary Signs & symptoms can be similar for different conditions Knowledge of pre-incident history helps Oxygen administration & TLC are beneficial to all diving illnesses & incidents

Diving Illness’ & Treatment Review Diving Illness’ & Treatment Review 85 06/2011